MRCP revision battle 43.1: Post renal-transplant complications

I'll admit it: I've been avoiding renal revision.  It's complicated I never understand it and it leaves me internally angry.  However dear friends I'm afraid the time has come to face a fully renal day.  On the menu is...


MRCP revision battle 43.1: Post renal-transplant complications
MRCP revision battle 43.2: Polycystic kidney disease and renal cysts
MRCP revision battle 43.3: Renal tubular acidosis
MRCP revision battle 43.4: Haematuria
MRCP revision battle 43.5: Renal calculi
MRCP revision battle 43.6: Focal Segmental Glomerulonephritis
MRCP revision battle 43.7: Acute renal failure




MRCP revision battle 43.1: Post renal-transplant complications

A kidney transplant can give a renal patient their life back as it frees them from endless dialysis sessions.  However, with kidney transplants come the risk of rejection/failure, complications and the burden of immunosupression...


Rejection


Acute rejection (less than 6 months post graft) presents as rising creatinine, possibly with fever and graft pain.  Biopsy would show immune cell infiltration.  Treatment is with high dose IV methylprednislone


Chronic rejection (greater than 6 months post graft) presents as gradually rising creatinine and proteinuria.  Biopsy would show fibrosis.  There is no effective treatment.


Overall graft survial is around 90% at 1 yr, 70% at 5 yrs and 50% at 10 yrs.




Non-renal complications

• Non-Hogkins Lymphoma - 20-50x increased risk due to ciclosporin use
• Skin cancer - 5-20x increased risk due to azothioprine
• Widespread warts/fungi/herpes zoster due to T cell supression by immunosupressives
  
• Cardiovascular disease - 10-20x increased risk
• CMV - give oral ganciclovir
• Pneumocystis carini pneumonia - give cotrimoxazole prophylaxis for first 6 months post transplant
• if previous TB give isoniazid for first year
• gout
• Diabetes - develops in 3-5%, ?due to tacrolimus

The common immunosupressants

• Ciclosporin
• inhibits T cell phosphatase calcineurin
• can cause tremor, hypertension, gum hypertrophy
• Tacrolimus
• decreases T cell activation
• ?risk of diabeets
• Azothioprine
• contraindicated with allopurinol as risk of life-threatening bone marrow supression
• is an anti-proliferation drug 
• TPMT test can be used to look for patients prone to toxicity
• side effects include bone marrow supression and pancreatitis.
• Mycophenolate
• anti-proliferative
• causes diarrhoea
• Sirolimus
• blocks IL2 so inhibits T cell division
• can provoke hyperlipidaemia
  

Now lets move on to polycystic kidney disease....